Physeal injuries
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Physeal injuries are disruptions in the cartilaginous physis of long bones, commonly affecting children's growth and quality of life, with a prevalence of 10-30% of childhood fractures. Management of these injuries involves appropriate diagnosis and treatment based on the type and age of the patient, with careful monitoring for potential complications such as growth arrest. Current trends in treatment include the use of gene therapy and tissue engineering to promote healing and prevent complications.
Physeal injuries
- 1. PHYSEAL INJURIES DR. BASSEY, A E ORTHOPAEDIC & TRAUMA SURGERY U.A.T.H, ABUJA
- 2. OUTLINE • INTRODUCTION DEFINITION STATEMENT OF IMPORTANCE EPIDEMIOLOGY • ANATOMY OF THE PHYSIS • AETIOPATHOGENESIS OF PHYSEAL INJURIES • CLASSIFICATION • MANAGEMENT HISTORY EXAMINATION INVESTIGATION TREATMENT • COMPLICATIONS • FOLLOW-UP/REHABILITATION • PROGNOSIS • CURRENT TRENDS • CONCLUSION
- 3. INTRODUCTION • DEFINITION - PHYSEAL INJURY IS A DISRUPTION IN THE CARTILAGINOUS PHYSIS OF LONG BONES THAT MAY INVOLVE EPIPHYSEAL AND/OR METAPHYSEAL BONE • IT IS A FAIRLY COMMON INJURY WITH A PROPENSITY FOR LIFELONG DIMINUTION OF PRODUCTIVITY AND QUALITY OF LIFE. IT IS THEREFORE IMPERATIVE FOR TODAY’S SURGEON TO HAVE ADEQUATE KNOWLEDGE AND SKILL IN ORDER TO DIAGNOSE THIS CONDITION EARLY AND INSTITUTE APPROPRIATE TREATMENT EXPEDITIOUSLY.
- 4. EPIDEMIOLOGY • PREVALENCE: 10 – 30% OF CHILDHOOD FRACTURES • AGE: BIMODAL PEAKS AT INFANCY & 10 – 12 YEARS • SEX: M>F • COMMONEST SITES: UPPER EXTREMITY>LOWER EXTREMITY DISTAL RADIUS DECREASING DISTAL HUMERUS FREQUENCY PROXIMAL TIBIA/FIBULA
- 5. ANATOMY OF THE PHYSIS • THE PHYSIS IS A SLAB OF HYALINE CARTILAGE LOCATED AT THE ENDS OF GROWING BONES BETWEEN THE EPIPHYSES AND METAPHYSES AND WHICH ARE RESPONSIBLE FOR THE GROWTH OF SUCH BONES • IT IS DIVIDED INTO 4 DISTINCT ZONES HISTOLOGICALLY: GERMINAL (RESTING) ZONE PROLIFERATIVE ZONE HYPERTROPHIC (MATURATION) ZONE ZONE OF CALCIFICATION
- 6. ANATOMY OF THE PHYSIS • GERMINAL ZONE CONTAINS CHONDROCYTES IN QUISENCE REPLENISHES PROLIFERATIVE ZONE INJURY CESSATION OF GROWTH • PROLIFERATIVE ZONE CONTAINS CHONDROCYTES IN MITOSIS RESPONSIBLE FOR INCREASE IN BONE LENGTH INJURY CESSATION OF GROWTH • HYPERTROPHIC ZONE CELLS ACCUMULATE GLYCOGEN/LIPIDS INCREASED ALKALINE PHOSPHATASE ACTIVITY WEAKEST ZONE AND SITE OF PHYSEAL FRACTURES • ZONE OF CALCIFICATION MINERALISATION OF CHONDROID MATRIX INFILTRATION BY METAPHYSEAL BLOOD VESSELS
- 8. AETIOPATHOGENESIS OF PHYSEAL INJURIES • AETIOLOGY – RTI FALLS SPORTS PLAYGROUND ACTIVITIES • BIOMECHANICS COMPRESSION SHEAR TENSION • FRACTURE CONFIGURATION USUALLY TRANSVERSE
- 9. CLASSIFICATION • SALTER-HARRIS (1963) – MOST WIDELY USED: ▫ TYPE 1: TRANVERSE FRACTURE IN HYPERTROPHIC ZONE ▫ TYPE 2: ABOVE FRACTURE VEERING OFF INTO METAPHYSIS TO INCLUDE A TRIANGULAR CHIP OF BONE ▫ TYPE 3: FRACTURE SPLITS EPIPHYSIS AND RUNS TRANVERSELY IN HYPERTROPHIC ZONE ▫ TYPE 4: FRACTURE RUNS LONGITUDINALLY SPLITTING EPIPHYSIS, PHYSIS & METAPHYSIS ▫ TYPE 5: LONGITUDINAL COMPRESSION INJURY • TYPE 6 ADDED IN 1969 – INJURY TO PERICHONDRAL RING • COMMONEST IS TYPE 2 (75% OF PHYSEAL INJURIES) • TYPE 5 IS RARE, MAY BE ASSOCIATED WITH DIAPHYSEAL FRACTURE • TYPES 3 – 6 HAVE HIGH RISK OF GROWTH ARREST
- 10. CLASSIFICATION
- 11. MANAGEMENT • HISTORY ▫ PAIN/SWELLING AROUND THE CONTIGUOUS JOINT ▫ UPPER LIMB – FUNCTION LIMITED BY PAIN ▫ LOWER LIMB – INABILITY TO BEAR WEIGHT ON AFFECTED LIMB ▫ PRECEEDING TRAUMATIC EVENT • EXAMINATION ▫ SWELLING ▫ DEFORMITY +/- (MINIMAL IF PRESENT) ▫ FOCAL TENDERNESS OVER PHYSIS ▫ LIMITED ROM
- 12. INVESTIGATION •X-RAYS WIDENING OF PHYSEAL GAP JOINT INCONGRUITY TILTING OF EPIPHYSIS PRESENCE OF DISPLACEMENT MAKES DIAGNOSIS MORE OBVIOUS TYPES 5 & 6 INJURIES ARE USUALLY DIAGNOSED RETROSPECTIVELY
- 13. X-RAY FINDINGS IN PHYSEAL INJURY – NORMAL PHYSIS
- 14. SALTER HARRIS TYPE 1
- 15. SALTER HARRIS TYPE 2
- 16. SALTER HARRIS TYPE 2
- 17. SALTER HARRIS TYPE 3
- 18. SALTER HARRIS TYPE 4
- 19. INVESTIGATION • CT TO VISUALISE FRACTURE ANATOMY IN SEVERELY COMMINUTED FRACTURES OF EPIPHYSIS AND METAPHYSIS • MRI MOST ACCURATE FOR FRACTURE ANATOMY IF DONE IN ACUTE PERIOD IDENTIFIES FORMATION OF BONY BRIDGE EARLIER THAN X-RAYS
- 20. TREATMENT • DEPENDS ON THE FOLLOWING FACTORS TYPE OF INJURY AGE OF PATIENT FRACTURE STABILITY • FOR TYPES 1 & 2 CLOSED REDUCTION AND IMMOBILIZATION IN CAST WILL USUALLY SUFFICE CHECK X-RAY IN 7 – 10 DAYS • FOR TYPES 3 & 4 REQUIRE ANATOMICAL REALIGNMENT VIA ORIF ORIF CAN BE WITH LAG SCREWS OR KIRSCHNER WIRES RUNNING PARALLEL TO PHYSIS • FOR TYPES 5 & 6 USUALLY DIAGNOSED RETROSPECTIVELY HOWEVER HIGH INDEX OF SUSPICION MUST BE MAINTAINED IN HIGH RISK INJURIES
- 23. COMPLICATIONS • GROWTH ARREST OCCURS BY DISRUPTION OF PHYSEAL BLOOD SUPPLY OR BONE BRIDGE FORMATION MAY BE PARTIAL OR COMPLETE • GROWTH ACCELERATION • SECONDARY OSTEOARTHRITIS
- 24. FOLLOW-UP/REHABILITATION • TYPES 1 & 2 FRACTURES ARE IMMOBILIZED FOR 3 – 6 WEEKS • TYPES 3 & 4 FRACTURES ARE IMMOBILIZED FOR 4 – 8 WEEKS • PATIENT RESUMES UNRESTRICTED PHYSICAL ACTIVITIES 4 – 6 WEEKS FOLLOWING REMOVAL OF IMPLANTS FOR FRACTURES THAT REQUIRED OPERATIVE FIXATION
- 25. FOLLOW-UP/REHABILITATION • FOLLOW-UP CHECK XRAYS ARE DONE AT 6 MONTHS AND 12 MONTHS POST INJURY AND MAY BE EXTENDED UP TO 2 YEARS AS GROWTH ARREST MAY BE DELAYED FOR THAT LONG
- 26. PROGNOSIS • AGE OF PATIENT AT TIME OF INJURY • TYPE OF INJURY • EXTENT OF CHONDRO-OSSEOUS DISRUPTION
- 27. CURRENT TRENDS • GROWTH PLATE INTERPOSITION FAT BONE WAX SILICON RUBBER POLYMETHYLMETHACRYLATE LABORATORY-DERIVED CHONDROCYTE ALLOGRAFT • GENE THERAPY & TISSUE ENGINEERING USE OF RETROVIRUSES TO INTRODUCE GENES CODING BMP-7 INTO RABBIT PERIOSTEAL MESENCHYMAL CELLS
- 28. CONCLUSION PHYSEAL INJURIES MAY NOT BE READILY OBVIOUS IN CHILDREN PRESENTING WITH PERIARTICULAR TRAUMA; A HIGH INDEX OF SUSPICION DURING EVALUATION, TREATMENT AND FOLLOW-UP OF SUCH PATIENTS IS OF THE ESSENCE TO FORESTALL FUTURE COMPLICATION.
- 29. THANK YOU
- 30. REFERENCES • Nayagam S. Principles of Fractures. In: Solomon L, Warwick D, Nayagam S. Apley’s System of Orthopaedics & Fractures. 9th ed. Hodder Arnold;2010: 727 – 730. • Mann DC, Rajmaira S. Distribution of physeal and non-physeal fractures in 2,650 long-bone fractures in children aged 0-16 years. J Pediatr Orthop. Nov-Dec 1990;10(6):713-6. • Neer CS, Horowitz BS. Fractures of the proximal humeral epiphyseal plate. Clin Orthop Rel Res. 1965;41:24-31. • http://emedicine.medscape.com/article/1260663-overview • http://www.wheelessonline.com/ortho/growth_plate_anatomy • http://www.orthobullets.com/pediatrics/4002/physeal-considerations